HIV Infection
See also the websites of ECDC http://www.ecdc.europa.eu/en/hiv-infection-and-aids, WHO http://www.who.int/news-room/fact-sheets/detail/hiv-aids and CDC http://www.cdc.gov/hiv/.
Essentials
- Identification of the HIV-infected persons is most essential.
- Suspect HIV infection on clinical grounds
- in patients exposed to HIV infection in unprotected sex or via injections
- in patients with a history of high-risk behaviour and who present with symptoms suggesting primary HIV infection
- in patients with unexplained immunosuppression or recurring bouts of fever of unknown origin, unintentional weight loss, dementia, oesophageal candidiasis, thrombocytopenia or anaemia without a clear cause.
- An HIV test is recommended in patients with pneumonia, especially if the disease has lead to hospitalization.
- An HIV test will become positive in 1 to 3 months after contracting the infection. To exclude the possibility of HIV infection, the development of antibodies should be followed up until 3 months have elapsed. The possible primary symptoms become manifest 2 to 6 weeks after the transmission.
- Persons infected with HIV should be referred to specialized care according to local guidelines immediately after the diagnosis has been made.
- There is no cure for HIV infection, but a combination therapy (cART = combination antiretroviral therapy, earlier HAART = highly active antiretroviral therapy) has improved the patients' life expectancy to be close to that of HIV-negative population.
- Various web sites provide information on HIV for the general public (see e.g. http://hivpoint.fi/en/). Find out about local services.
Natural course of HIV infection
Primary infection
- Primary HIV infection develops in 30-50% of infected patients, 2-6 weeks after contracting the virus.
- The symptoms may include: fever, tiredness, sore throat, headache, diarrhoea, myalgia, arthralgia and occasionally enlarged lymph nodes as well as an eruption of small papules on the body. Primary infection often resembles mononucleosis.
- The symptoms resolve within a month.
- Diagnosis is made difficult by the fact that during primary infection some patients still have a negative result in the HIV-AgAb test. HIV-AgAb test should thus be repeated after 3 months if primary infection is suspected and the first test remained negative.
Asymptomatic phase
- Lasts for several years, in some cases over 10 years.
Symptomatic HIV infection
- CD4 cell count has often decreased to below 0.35 × 109 /l.
- An increasing viral load is often predictive of symptom emergence.
- Symptoms are non-specific, such as weight loss, fever and persistent diarrhoea.
- Herpes zoster (shingles), oropharyngeal candidiasis and seborrhoeic eczema are also indicative of reduced immune response. See also picture F1.
AIDS
- AIDS is defined as an HIV infection with at least one of the officially listed opportunistic associated diseases.
- The introduction of cART has significantly reduced the occurrence of opportunistic diseases.
- Common associated diseases include:
- fungal oesophagitis or stomatitis
- Pneumocystis jirovecii pneumonia
- infections caused by environmental mycobacteria (M. avium-intracellulare)
- Kaposi's sarcoma.
- Tuberculosis is a common associated disease in many countries.
- Lymphoma can also be an associated disease.
- An HIV test is indicated particularly in the following clinical situations:
- there is a history of high-risk behaviour: unprotected sex with occasional partners or with prostitutes, or use of intravenous drugs
- sexually transmitted diseases
- fever, diarrhoea, weight loss or dementia of unknown origin
- unexplained thrombocytopenia
- pneumonia caused by Pneumocystis jiroveci (opportunistic pneumonia typically presenting with slow onset, dyspnoea on exertion, hypoxaemia, and mild or moderate fever)
- widespread oral candidiasis associated with dysphagia or pain on swallowing (oesophageal candidiasis)
- Kaposi's sarcoma (wine-red or violet spots or tumours in the palate, gums or skin)
- hepatitis B or C is diagnosed
- patient has symptoms and signs suggesting primary HIV-infection
- cervical cancer, at least if it is diagnosed in a young woman
- lymphoma diagnosed
- tuberculosis or an infection by environmental mycobacteria
- community-acquired pneumonia.
- An HIV test is recommended to be included in the health check-ups of immigrants coming from endemic regions.
- An HIV test should always be performed when requested by the patient. HIV testing should be offered if one knows that behaviour exposing a person to HIV infection, such as unprotected occasional sexual contacts or intravenous drug use, has taken place.
- The patient should be informed about an intention of HIV testing. If the patient declines the test, the problems and possible harm caused by the delayed diagnosis, both for the patient himself/herself, the treating personnel (extra investigations and prolonged treatment time) and other people (infection risk), should be further explored with the patient.
- The result of an HIV test is reliable when 3 months have passed after the exposure. During the follow-up period, a condom must be used during sexual intercourse Condom Effectiveness in Reducing Heterosexual HIV Transmission. Safe sex is especially important when suspecting a recent HIV infection since the number of viruses is high in the initial stage.
- Pregnant women are offered voluntary screening at maternity clinics.
Diagnosis
- Combined HIV-AgAb test
- When a patient is for the first time identified as HIV positive, it is advisable to take a control sample to exclude potential mix-up of samples. Additional samples may be needed e.g. for archival purposes according to national legislation. These tests are usually taken within specialized care. Find out about local policies.
- The test will become positive 2-4 weeks after symptom onset or at latest 3 months after contracting the virus. If the person has been given prophylactic HIV medication after the exposure, test results are monitored for up to 6 months from the exposure.
- Consult local guidelines and policies concerning the appropriate place of treatment and monitoring of patients with HIV infection. Make a referral to specialist care as soon as the infection is detected.
- Adequate time must be allocated for breaking the news of a positive test result. The patient should also be given contact details of how to obtain more information or psychological support (HIV help lines, peer support organisations, etc.).
- If the result is negative the patient should be given advice regarding high-risk behaviour and the possible need of a repeat test.
- Any unit carrying out HIV testing should be able to provide a patient whose HIV test result is positive with general information regarding the mode of HIV transmission, course of the disease and the treatment choices available. The unit should also be prepared to answer any questions relating to daily hygiene needs etc. The Effects of HIV Counseling and Testing (HIV CT) on Risk-Related Practices and Help-Seeking Behaviour.
- The disease staging and the assessment of an individual patient's prognosis, as well as planning of the treatment, are carried out in specialized care.
- The physician who makes an HIV infection diagnosis should initiate contact tracing and the tracing should be carried out by the treating infectious disease specialist and the municipal physician responsible for control of infectious diseases. Check also local policies and practices.
- An official notification of an infectious disease should be made.
- If the patient is an intravenous drug user, a hepatitis B vaccination programme is commenced unless the patient has had the disease or has already been vaccinated. Also the HCV antibodies should be investigated.
- The follow-up of the patient usually takes place permanently within specialized care. Depending on local policies, the investigations and treatment may be provided free of charge.
- Treatment of an HIV infection requires specialist skills, and the prescription and monitoring of drug therapies should take place in appropriate centres with special expertise.
- The development of HIV drugs has significantly improved the prognosis of an HIV infection. No cure exists, but it may be possible to add several tens of years to the life expectancy of an HIV positive patient. Quality of life has also improved significantly as has the patients' ability to continue in working life.
- Starting treament in time is essential for the prognosis.
- Drug therapy for HIV infection is offered to all infected persons who are capable of committing to the therapy. Starting drug therapy is particularly important for those with a symptomatic disease and for pregnant women (to prevent vertical transmission) Interventions for Reducing Mother-to-Child Transmission of HIV Infection.
- The treatment is usually carried out with the combination of three antiviral drugs (cART) Three- or Four-Drug Versus Two-Drug Antiretroviral Maintenance Regimens for HIV Infection.
- During effective drug treatment, the viral load in plasma is below detection threshold (20 copies/ml) and due to successful treatment, the CD4 cell count increases, the risk of associated diseases decreases and the transmission risk significantly decreases.
- Once antiviral drug therapy has been started, its uninterrupted continuation is of vital importance.
- Development of drug resistance and loss of efficacy may follow irregular adherence to therapy.
- The treatment must not be interrupted without prior consultation with the treating unit.
- Patient compliance is the most important factor in successful drug therapy for HIV infection.
- To facilitate dosing at the same time every day involves adjusting ones lifestyle to enable the treatment.
- To maintain a long-term treatment response, at least 95% of the drug doses should be taken at the specified time.
- The risk of foetal transmission is below 1% provided that the maternal infection is detected in time and that the cART-treatment decreases the viral load in maternal plasma below detection threshold before delivery.
- See also the European EACS guideline http://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html and the NIH guideline http://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf.
HIV and the general practitioner
- These patients will visit their GP with common public health problems, such as hypertension, diabetes, common infections, skin or dental problems or with problems totally unrelated to their positive HIV status.
- HIV drugs interact with several other drugs. There is potential for too high or too low concentrations of some of the drugs. If necessary, consult a physician from the centre responsible for the patient's antiviral pharmacotherapy. There are also easy-to-use online tools, such as the Interaction Checker by the University of Liverpool http://hiv-druginteractions.org/.
- When an HIV positive patient presents with a febrile illness the treating specialist unit should be readily consulted over the telephone, particularly if the patient's CD4 count is significantly low.
- By prophylactic drug treatment (PEP = post-exposure prophylaxis) it is possible to significantly reduce the transmission risk of HIV infection after both work-related Occupational Exposure to Blood and Body Secretions and other exposure incidents (e.g. condom breakage during intercourse of a HIV discordant couple). Prophylactic treatment is recommended to be started as soon as possible, preferably within 2 hours but not later than 72 hours after the exposure. The assessment concerning PEP is usually done in specialized care.
- Prophylactic drug treatment that is started before exposure (PrEP = pre-exposure prophylaxis), when used correctly, has been shown to prevent HIV infections associated with sex between men, heterosex, and the use of illegal intravenous drugs. Check locally applied indications for PrEP.
- Certain HIV drugs are used for PrEP. Limitations concerning the prescribing of these drugs may apply. Depending on local policies, PrEP may be free of charge for the patient.
- The assessment concerning PrEP and starting the medication may be organized differently in different areas. Check local organization of care. The provider of PrEP treatment must be very familiar with HIV infections, as well as with sexually transmitted diseases and sexual behaviour.
- HIV infection must be ruled out by an HIV-AgAb test before referring the patient for a PrEP assessment.
- PrEP requires commitment. The treatment necessitates regular blood tests and medication pickup.
- PrEP only protects against HIV infection. Also the risk of other infections should be reviewed together with the patient when discussing PrEP. Condom use during sex and the use of clean injecting equipment is important, even when starting PrEP.
- At the same time, make sure that the patient has received the vaccines intended for him or her. Check the national immunization programme and other relevant local policies.
- Vaccines against hepatitis A and/or B, for example, may be available to injecting drug users, to men who have sex with men, and/or to sex workers, possibly free of charge.
The working capacity of HIV carriers
- During the asymptomatic phase the working capacity of the patient usually remains normal.
- The decreased working capacity during primary infection is transient. Loss of working capacity caused by AIDS may be restored during antiviral treatment.
- Infection risk does not usually contribute towards the patient's inability to work.
Hygiene guidelines for people caring for a patient with HIV
- When exposure to blood is a possibility, gloves and a facial shield protecting also the eyes should be worn.
- Gloves should be worn when taking blood samples, but there is no need to wear a facial shield (if vacuum tubes are used).
- Particular attention should be paid to following recommended procedures in order to avoid needle stick injuries.
- Occupational exposure to HIV, see Occupational Exposure to Blood and Body Secretions.
References
- Ryom L, Cotter A, De Miguel R ym. 2019 update of the European AIDS Clinical Society Guidelines for treatment of people living with HIV version 10.0. HIV Med 2020;21(10):617-624. [PubMed]